Oncology & Hematology Coding Alert

Differentiate seeds and markers before choosing 55875 or 55876.

Brachytherapy seed placement coding challenges even veteran coders because physicians often work together on the service, which limits what you can report. Overcome these challenges with three expert tips, and avoid costly brachytherapy denials.

Skip Separate Cysto Coding

Traditionally, a urologist will place the needles to implant the brachytherapy seeds. The physician providing the service will report 55875 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy), says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook.

Don't miss: Pay special attention to the fact that 55875's descriptor says "with or without cystoscopy." The physician may perform a cystoscopic examination to determine whether any seeds have been misplaced into the bladder or prostatic urethra. Even though he performed a cystoscopic examination and may have a separate diagnosis (such as history of hematuria) indicating medical necessity for the procedure, you still cannot separately report 52000 (Cystourethroscopy [separate procedure]).

According to the Correct Coding Initiative (CCI), Medicare bundles 52000 into 55875, and you cannot bypass the edit with a modifier, Ferragamo stresses. Remember, however, some private and commercial payers may reimburse for the cystoscopic examination, so check with your individual payers.

Additionally: If your physician uses ultrasonic guidance to place the needles, you should report 76965 (Ultrasonic guidance for interstitial radioelement application) in addition to 55875. Because this procedure is usually performed in a hospital, the facility will bill for the technical component. In that case, the physician reporting 76965 should append modifier 26 (Professional component) to indicate she's reporting only the professional component.

Avoid the 55875 vs. 55876 Pitfall

You might be tempted to report 55876 (Placement of interstitial device[s] for radiation therapy guidance [e.g., fiducial markers, dosimeter], percutaneous, prostate, single or multiple) for brachytherapy claims. According to the May 2007 CPT Assistant, however, you should report 55876 only when your physician implants metallic marker seeds (also called fiducial markers) -- not brachytherapy needles or seeds -- into the prostate gland.

The difference: "Code 55876 is a placement of markers for measuring radiation doses or targeting radiation treatment," says Linda Cahill, CPC, clinical coordinator/lead coder, for a Cincinnati practice. "The markers are visible by ultrasound and fluoroscopy, allowing an accurate triangulation of the tissue to be treated. This code reports the insertion of one or more of these capsules or markers."

In contrast: "Code 55875 is the placement of needles or catheters for the interstitial radioelement application/brachytherapy," Cahill explains. Typically, "the urologist would place the needles or catheters, and the radiation oncologist would place the radioactive isotopes or seeds [via these needles] into the prostate gland."

Scour Documentation for Division of Services

If the radiation oncologist works with a urologist during a prostatic brachytherapy procedure, the physician who places the needles or catheters into the prostate and typically performs the cystoscopy should report 55875. If both physicians report the code, the payer will deny one of the claims.

The services you're more likely to see for your radiation oncology claims include treatment plan (77261-77263), simulation (77280-77295), isodose plan (77326-77328), dosimetry calculation (77300), treatment device (such as 77332), and radiation source application (77776-77778).

Don't assume: Although the radiation oncologist may perform an additional volume study (76873, Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]) during treatment planning, the urologist may elect to perform this volume study himself, provided he has the necessary special equipment. He may perform this study prior to seed insertion or at the time of seed implantation. If your physician does perform the volume study himself, you should code for it. If performed in a hospital, bill 76873-26, for interpreting and applying the test results.

Bottom line: Every case -- and every practice -- is different. Make sure you're checking the documentation to see which physician performed each service before you automatically code. Report only the services and procedures your oncologist performed.